An Anesthesia Quality Improvement Plan to Improve Postoperative Pain Outcomes after Hysterectomy
Abstract
An anesthesia quality improvement initiative implemented an evidence-based, preemptive, preventive multimodal analgesic regimen to improve perioperative pain outcomes for women undergoing hysterectomy. Though statistical significance was not achieved, clinically significant decreases in Post Anesthesia Care Unit (PACU) narcotic usage, pain ratings, time in the PACU, and opioid related side effects were observed. This analgesic regimen was easily implemented, readily modifiable, and suitable for expansion to multiple surgical populations to supplement customary anesthesia perioperative care.References
1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003 Aug;97(2):534-40. doi:10.1213/01.ANE.0000068822.10113.9E.
2. Oderda GM, Evans RS, Lloyd J, et al. Cost of opioid-related adverse drug events in surgical patients. J Pain Symptom Manage. 2003;25:276-83. Mar;27(1):62-70. doi:10.3109/15360288. 2012.751956. Epub 2013 Jan 9.
3. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology. 2010 Jan;112(1):220-5. doi: 10.1097/ALN.0b013e3181c6316e.
4. Kaiser Family Foundation. Hospital Adjusted Expenses per Inpatient Day, 2011. http://kff.org/other/state-indicator/expenses-per-inpatient-day/. Accessed March 23, 2014.
5. Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TS. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology. 2007 May;106(5):1003-12.
6. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug;13(8):715-24. doi: 10.1016/j.jpain.2012.03.009. Epub 2012 May 16.
7. Chandrakantan A, Glass PS. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth. 2011 Dec;107 Suppl 1:i27-40. doi: 10.1093/bja/aer358.
8. Azari L, Santoso JT, Osborne SE. Optimal pain management in total abdominal hysterectomy. Obstet Gynecol Surv. 2013 Mar;68(3):215-27. doi: 10.1097/OGX.0b013e31827f5119.
9. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD003677. doi: 10.1002/14651858.CD003 677.pub4.
10. Muzii L, Basile S, Zupi E, Marconi D, Zullo MA, Manci N, Bellati F, Angioli R, Benedetti Panici P. Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy: a prospective, randomized, multicenter study. J Minim Invasive Gynecol. 2007 Sep-Oct;14(5):610-5.
11. Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol. 1999 Feb;180(2 Pt 1):270-5.
12. Elvir-Lazo OL, White PF. Postoperative pain management after ambulatory surgery: role of multimodal analgesia. Anesthesiol Clin. 2010 Jun;28(2):217-24. doi: 10.1016/j.anclin.2010 .02.011.
13. American Association of Nurse Anesthetists. Standards for Nurse Anesthesia Practice, 2013. www.aana.com/resources2/professionalpractice/Documents/PPM%20Standards%20for%20Nurse%20Anesthesia%20Practice.pdf. Accessed September 2, 2014.
14. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012 Feb;116(2):248-73. doi: 10.1097/ALN.0b013e31823c1030.
15. Grape S, Tramèr MR. Do we need preemptive analgesia for the treatment of postoperative pain? Best Pract Res Clin Anaesthesiol. 2007 Mar;21(1):51-63.
16. United States Code of Federal Regulations. Definitions. 2010. Title 32, Volume 2, Chapter 1, Section 219-102, p. 428. http://www.ecfr.gov/cgi-bin/text-idx?SID=d0cd93963ee90170 b994ae5e29b206de&node=se32.2.219_1102&rgn=div8. Accessed September 2, 2014.
17. Abel, M. (2014, April 1). [Memorandum to Jacob Deeds]. Copy in possession of Jacob Deeds.
18. US Army Medical Department. Welcome to XXXXXXX. http://www.XXXX.amedd.army.mil/. Accessed September 2, 2014.
19. Tricare. Eligibility. http://www.tricare.mil/eligibility. Accessed September 2, 2014.
20. Leiter, E (March 20, 2014). [Personal Communication to Jacob Deeds]. Copy in possession of Jacob Deeds.
21. Van der Westhuizen J, Kuo PY, Reed PW, & Holder K. Randomised controlled trial comparing oral and intravenous paracetamol (acetaminophen) plasma levels when given as preoperative analgesia. Anaesthesia and Intensive Care. 2011 Mar;39(2), 242–246.
22. Singla NK, Parulan C, Samson R, Hutchinson J, Bushnell R, Beja EG, Ang R, Royal MA. Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral, or rectal acetaminophen. Pain Pract. 2012 Sep;12(7):523-32. doi: 10.1111/j.1533-2500.2012.00556.x.
23. Ajori L, Nazari L, Mazloomfard MM, Amiri Z. Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Arch Gynecol Obstet. 2012 Mar;285(3):677-82. doi: 10.1007/s00404-011-2023-6.
24. Behdad S, Ayatollahi V, Bafghi AT, Tezerjani MD, Abrishamkar M. Effect of gabapentin on postoperative pain and operation complications: a randomized placebo controlled trial. West Indian Med J. 2012 Mar;61(2):128-33.
25. Frouzanfard F, Fazel MR, Abolhasani A, Fakharian E, Mousavi G, Moravveji A. Effects of gabapentin on pain and opioid consumption after abdominal hysterectomy. Pain Res Manag. 2013 Mar-Apr;18(2):94-6.
26. Ghai A, Gupta M, Hooda S, Singla D, Wadhera R. A randomized controlled trial to compare pregabalin with gabapentin for postoperative pain in abdominal hysterectomy. Saudi J Anaesth. 2011 Jul;5(3):252-7. doi: 10.4103/1658-354X.84097.
27. Khan MA, Siddiqi KJ, Aqeel M. Effect of gabapentin on opioid requirements in patients undergoing total abdominal hysterectomy. Anaesth Pain & Intensive Care 2013;17(2):131-135.
28. Rorarius MG, Mennander S, Suominen P, Rintala S, Puura A, Pirhonen R, Salmelin R, Haanpää M, Kujansuu E, Yli-Hankala A. Gabapentin for the prevention of postoperative pain after vaginal hysterectomy. Pain. 2004 Jul;110(1-2):175-81.
29. Sen H, Sizlan A, Yanarates O, Emirkadi H, Ozkan S, Dagli G, Turan A. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50. doi: 10.1213/ANE.0b013e3181b65ea0.
30. Turan A, Karamanlioğlu B, Memiş D, Usar P, Pamukçu Z, Türe M. The analgesic effects of gabapentin after total abdominal hysterectomy. Anesth Analg. 2004 May;98(5):1370-3, table of contents.
31. Arici S, Gurbet A, Türker G, Yavaşcaoğlu B, Sahin S. Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. Agri. 2009 Apr;21(2):54-61.
32. Moon YE, Lee YK, Lee J, Moon DE. The effects of preoperative intravenous acetaminophen in patients undergoing abdominal hysterectomy. Arch Gynecol Obstet. 2011 Dec;284(6):1455-60. doi: 10.1007/s00404-011-1860-7.
33. Durmus M, Kadir But A, Saricicek V, Ilksen Toprak H, Ozcan Ersoy M. The post-operative analgesic effects of a combination of gabapentin and paracetamol in patients undergoing abdominal hysterectomy: a randomized clinical trial. Acta Anaesthesiol Scand. 2007 Mar;51(3):299-304.
34. Syal K, Goma M, Dogra RK, Ohri A, Gupta AK, Goel A. "Protective premedication": a comparative study of acetaminophen, gabapentin and combination of acetaminophen with gabapentin for post-operative analgesia. J Anaesthesiol Clin Pharmacol. 2010 Oct;26(4):531-6.
35. Vadivelu, N, Mitra, S, Narayan, D. Recent advances in postoperative pain management. Yale J Biol Med. 2010 Mar; 83(1): 11–25.
36. Macario, A. What does one minute of operating room time cost? J Clin Anesth. 2010 Jun;22(4):233-6. doi: 10.1016/j.jclinane.2010.02.003.
37. Quintana, J (February 3, 2015). Pharmacy Supply. [Personal Communication to Jacob Deeds].
38. Oral Acetaminophen, IV Acetaminophen [Search Results]. Clinical Trials.gov. https://clinicaltrials.gov/ct2/results?term=oral+acetaminophen+IV+acetaminophen&Search=Search. Accessed February 3, 2015.
2. Oderda GM, Evans RS, Lloyd J, et al. Cost of opioid-related adverse drug events in surgical patients. J Pain Symptom Manage. 2003;25:276-83. Mar;27(1):62-70. doi:10.3109/15360288. 2012.751956. Epub 2013 Jan 9.
3. White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology. 2010 Jan;112(1):220-5. doi: 10.1097/ALN.0b013e3181c6316e.
4. Kaiser Family Foundation. Hospital Adjusted Expenses per Inpatient Day, 2011. http://kff.org/other/state-indicator/expenses-per-inpatient-day/. Accessed March 23, 2014.
5. Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TS. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology. 2007 May;106(5):1003-12.
6. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug;13(8):715-24. doi: 10.1016/j.jpain.2012.03.009. Epub 2012 May 16.
7. Chandrakantan A, Glass PS. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth. 2011 Dec;107 Suppl 1:i27-40. doi: 10.1093/bja/aer358.
8. Azari L, Santoso JT, Osborne SE. Optimal pain management in total abdominal hysterectomy. Obstet Gynecol Surv. 2013 Mar;68(3):215-27. doi: 10.1097/OGX.0b013e31827f5119.
9. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD003677. doi: 10.1002/14651858.CD003 677.pub4.
10. Muzii L, Basile S, Zupi E, Marconi D, Zullo MA, Manci N, Bellati F, Angioli R, Benedetti Panici P. Laparoscopic-assisted vaginal hysterectomy versus minilaparotomy hysterectomy: a prospective, randomized, multicenter study. J Minim Invasive Gynecol. 2007 Sep-Oct;14(5):610-5.
11. Marana R, Busacca M, Zupi E, Garcea N, Paparella P, Catalano GF. Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study. Am J Obstet Gynecol. 1999 Feb;180(2 Pt 1):270-5.
12. Elvir-Lazo OL, White PF. Postoperative pain management after ambulatory surgery: role of multimodal analgesia. Anesthesiol Clin. 2010 Jun;28(2):217-24. doi: 10.1016/j.anclin.2010 .02.011.
13. American Association of Nurse Anesthetists. Standards for Nurse Anesthesia Practice, 2013. www.aana.com/resources2/professionalpractice/Documents/PPM%20Standards%20for%20Nurse%20Anesthesia%20Practice.pdf. Accessed September 2, 2014.
14. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012 Feb;116(2):248-73. doi: 10.1097/ALN.0b013e31823c1030.
15. Grape S, Tramèr MR. Do we need preemptive analgesia for the treatment of postoperative pain? Best Pract Res Clin Anaesthesiol. 2007 Mar;21(1):51-63.
16. United States Code of Federal Regulations. Definitions. 2010. Title 32, Volume 2, Chapter 1, Section 219-102, p. 428. http://www.ecfr.gov/cgi-bin/text-idx?SID=d0cd93963ee90170 b994ae5e29b206de&node=se32.2.219_1102&rgn=div8. Accessed September 2, 2014.
17. Abel, M. (2014, April 1). [Memorandum to Jacob Deeds]. Copy in possession of Jacob Deeds.
18. US Army Medical Department. Welcome to XXXXXXX. http://www.XXXX.amedd.army.mil/. Accessed September 2, 2014.
19. Tricare. Eligibility. http://www.tricare.mil/eligibility. Accessed September 2, 2014.
20. Leiter, E (March 20, 2014). [Personal Communication to Jacob Deeds]. Copy in possession of Jacob Deeds.
21. Van der Westhuizen J, Kuo PY, Reed PW, & Holder K. Randomised controlled trial comparing oral and intravenous paracetamol (acetaminophen) plasma levels when given as preoperative analgesia. Anaesthesia and Intensive Care. 2011 Mar;39(2), 242–246.
22. Singla NK, Parulan C, Samson R, Hutchinson J, Bushnell R, Beja EG, Ang R, Royal MA. Plasma and cerebrospinal fluid pharmacokinetic parameters after single-dose administration of intravenous, oral, or rectal acetaminophen. Pain Pract. 2012 Sep;12(7):523-32. doi: 10.1111/j.1533-2500.2012.00556.x.
23. Ajori L, Nazari L, Mazloomfard MM, Amiri Z. Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Arch Gynecol Obstet. 2012 Mar;285(3):677-82. doi: 10.1007/s00404-011-2023-6.
24. Behdad S, Ayatollahi V, Bafghi AT, Tezerjani MD, Abrishamkar M. Effect of gabapentin on postoperative pain and operation complications: a randomized placebo controlled trial. West Indian Med J. 2012 Mar;61(2):128-33.
25. Frouzanfard F, Fazel MR, Abolhasani A, Fakharian E, Mousavi G, Moravveji A. Effects of gabapentin on pain and opioid consumption after abdominal hysterectomy. Pain Res Manag. 2013 Mar-Apr;18(2):94-6.
26. Ghai A, Gupta M, Hooda S, Singla D, Wadhera R. A randomized controlled trial to compare pregabalin with gabapentin for postoperative pain in abdominal hysterectomy. Saudi J Anaesth. 2011 Jul;5(3):252-7. doi: 10.4103/1658-354X.84097.
27. Khan MA, Siddiqi KJ, Aqeel M. Effect of gabapentin on opioid requirements in patients undergoing total abdominal hysterectomy. Anaesth Pain & Intensive Care 2013;17(2):131-135.
28. Rorarius MG, Mennander S, Suominen P, Rintala S, Puura A, Pirhonen R, Salmelin R, Haanpää M, Kujansuu E, Yli-Hankala A. Gabapentin for the prevention of postoperative pain after vaginal hysterectomy. Pain. 2004 Jul;110(1-2):175-81.
29. Sen H, Sizlan A, Yanarates O, Emirkadi H, Ozkan S, Dagli G, Turan A. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesth Analg. 2009 Nov;109(5):1645-50. doi: 10.1213/ANE.0b013e3181b65ea0.
30. Turan A, Karamanlioğlu B, Memiş D, Usar P, Pamukçu Z, Türe M. The analgesic effects of gabapentin after total abdominal hysterectomy. Anesth Analg. 2004 May;98(5):1370-3, table of contents.
31. Arici S, Gurbet A, Türker G, Yavaşcaoğlu B, Sahin S. Preemptive analgesic effects of intravenous paracetamol in total abdominal hysterectomy. Agri. 2009 Apr;21(2):54-61.
32. Moon YE, Lee YK, Lee J, Moon DE. The effects of preoperative intravenous acetaminophen in patients undergoing abdominal hysterectomy. Arch Gynecol Obstet. 2011 Dec;284(6):1455-60. doi: 10.1007/s00404-011-1860-7.
33. Durmus M, Kadir But A, Saricicek V, Ilksen Toprak H, Ozcan Ersoy M. The post-operative analgesic effects of a combination of gabapentin and paracetamol in patients undergoing abdominal hysterectomy: a randomized clinical trial. Acta Anaesthesiol Scand. 2007 Mar;51(3):299-304.
34. Syal K, Goma M, Dogra RK, Ohri A, Gupta AK, Goel A. "Protective premedication": a comparative study of acetaminophen, gabapentin and combination of acetaminophen with gabapentin for post-operative analgesia. J Anaesthesiol Clin Pharmacol. 2010 Oct;26(4):531-6.
35. Vadivelu, N, Mitra, S, Narayan, D. Recent advances in postoperative pain management. Yale J Biol Med. 2010 Mar; 83(1): 11–25.
36. Macario, A. What does one minute of operating room time cost? J Clin Anesth. 2010 Jun;22(4):233-6. doi: 10.1016/j.jclinane.2010.02.003.
37. Quintana, J (February 3, 2015). Pharmacy Supply. [Personal Communication to Jacob Deeds].
38. Oral Acetaminophen, IV Acetaminophen [Search Results]. Clinical Trials.gov. https://clinicaltrials.gov/ct2/results?term=oral+acetaminophen+IV+acetaminophen&Search=Search. Accessed February 3, 2015.
Published
2016-08-12
How to Cite
DEEDS, DNP, CRNA, ANC, USA, Jacob Lee et al.
An Anesthesia Quality Improvement Plan to Improve Postoperative Pain Outcomes after Hysterectomy.
Anesthesia eJournal, [S.l.], v. 4, n. 1, aug. 2016.
ISSN 2333-2611.
Available at: <https://anesthesiaejournal.com/index.php/aej/article/view/34>. Date accessed: 20 apr. 2024.
Issue
Section
Articles
Keywords
preemptive; preventive; analgesia; gabapentin; IV acetaminophen; hysterectomy; postoperative pain; performance improvement; quality improvement
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Authors agree to the Creative Commons License listed below, which can be viewed by clicking the link below.
This work will be licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
